What’s going on with A&E waiting times?

There are three main types of A&E departments in England.

Type 1 departments are what most people might traditionally think of as an A&E service. They are major emergency departments that provide a consultant-led 24-hour service with full facilities for resuscitating patients, for example patients in cardiac arrest. Type 1 departments, which are operated by 124 NHS trusts, account for the majority of attendances.

Type 2 departments are consultant-led facilities but for specific conditions, for example, eye conditions or dental problems.

Type 3 departments treat minor injuries and illnesses, such as stomach aches, cuts and bruises, some fractures and lacerations, and infections or rashes. 

Being treated quickly in A&E is important for both for clinical outcomes and the experience of patients: delays in care for patients arriving in A&E have been associated with increased mortality and illness. 

The most high-profile measure of A&E performance in England is the four-hour standard. This refers to the pledge in the NHS

Constitution that at least 95 per cent of patients attending A&E should be admitted to hospital, transferred to another provider, or discharged within four hours.

A&E waiting times are often used as a barometer for overall performance of the NHS and social care system. This is because A&E waiting times are affected by activity and pressures in other services such as the ambulance service, primary care, community-based care and social care services. For example, patients cannot be admitted quickly from A&E to a hospital ward if hospitals are full due to delays in transferring patients to other NHS services or in arranging social care.

However, measuring the proportion of people seen within four hours does not provide a full picture of how A&Es are performing and we should be cautious about placing too much emphasis on the four-hour standard or any single measure of A&E performance. The 2020 national survey of patients who have used urgent and emergency care services also shows these services receive high satisfaction scores overall, although, for example, more can be done to improve communication with patients as they are discharged from A&E. 

A&E waiting times have worsened substantially in recent years, after a decade of funding settlements that failed to keep up with demand for services and growing staff shortages. The NHS has not met the four-hour standard at national level in any year since 2013/14, and the standard has been missed in every month since July 2015 (see Figure 1).

The four-hour standard is measured across all types of A&E department, but performance is poorest in type 1 (major) A&Es and this is where the majority of breaches of the four-hour standard occur.

Patients are waiting longer in A&E departments due to a wide range of factors including rising demand for services and reduced capacity to meet this demand.

Rising A&E attendances

High volumes of A&E attendances can lead to over-crowding, rising pressure on A&E services and poorer experience for patients. Attendances were lower than usual during the pandemic due to the availability of services and public attitudes to using health care services (see Figure 3). But aside from the Covid-19 period, the overall trend shows the number of people going to A&E has risen substantially over time. In 2019/20 there were 25.0 million attendances at A&E, compared to 21.5 million attendances in 2011/12. 

Rising emergency admissions to hospital

However, the increased pressure on A&E departments is more closely associated with rising numbers of emergency admissions to hospital rather than the increase in A&E attendances. In recent years, as demand for hospital inpatient care increased, the capacity to meet this demand has come under increasing pressure due to an insufficient number of hospital beds and severe staff shortages (see our explainers on A&E waiting times, hospital beds and delayed discharges for more information).

Fewer hospital beds

Although medical advances have reduced the average length of time people spend in hospital and allow beds to be ‘turned around’ or made available again more quickly, rising emergency admissions are placing increasing pressure on available resources, including hospital beds. 

These pressures are demonstrated by high levels of bed occupancy in NHS hospitals, which are closely associated with longer waiting times in A&E. Particularly in the winter months, hospitals are routinely operating with bed-occupancy rates above 92 per cent – the level at which the Department of Health and Social Care suggests that hospitals will struggle to deal with emergency admissions.

One of the clearest indications of the link between A&E waiting times and hospital bed occupancy is the number of patients who experience ‘trolley waits’1  in A&E departments – ie, a long wait between a decision to admit the patient being made in A&E and the patient actually being admitted to a hospital bed. These waits have substantially increased in recent years. 

Pressures on other services and changing clinical practice

Delays in discharging patients who are medically fit to leave hospital (known as ‘delayed transfers of care’ or ‘stranded patients’) are another factor driving up bed-occupancy rates. This can mean both poorer experience for the patients waiting to be discharged and a lack of available beds for new patients requiring admission from A&E. These delays can arise from a lack of available capacity in social care and NHS settings outside of hospital – including intermediate care or ‘step-down’ facilities that help care for patients after they leave hospital. 

Recent analysis has also indicated that waiting times in A&E may be increasing due to advances in medical practice. For example, some patients who would previously have been admitted to hospital can now be fully treated in A&E with more investigations and treatments. Patients with simpler clinical needs who could be treated quickly in A&E may now also be increasingly treated out of hospital, for example, being treated by ambulance services at the scene of an injury. 

Staffing pressures

A&E departments face longstanding challenges in recruiting and retaining sufficient staff to cope with rising demand. The Royal College of Emergency Medicine notes that emergency medicine has a high attrition rate from doctors in training, high early retirement rates for experienced clinicians, and significant reliance on temporary locum clinical staff. In a recent General Medical Council survey, nearly three-quarters of emergency medicine trainees rated the intensity of their workload as heavy or very heavy, substantially more than any other specialty.

A range of national policies has been put in place over recent years to boost the numbers of clinical staff in A&E departments through increased recruitment and improved retention of existing staff. Between 2012 and 2019 the number of emergency medicine consultants increased by 7 per cent each year. Over this time, other professional roles, such as advanced clinical practitioners and physician associates, have also been developed to play a greater role in delivering A&E services to relieve pressures on departments.

However, it remains difficult to recruit and retain sufficient staff in emergency care and other key services. Shortages of nurses and medical staff are also reported in specialties such as acute general medicine. Staffing shortages in these key areas will reduce the ability of hospitals to admit patients quickly from A&E departments or to provide specialist advice to patients within A&E departments who could be treated and discharged, further increasing waiting times.

• 1 The number of ‘trolley waits’ can be affected by variation in how different hospitals arrive at (and record the time of) the ‘decision to admit’. Because of this, NHS Digital has begun to produce data on the number of patients who spend a total of 12 hours or more in A&E.

Age of patients

NHS Digital publishes detailed annual reports of activity at A&E departments in England. These reports show that the age-profile of patients attending A&E has remained relatively stable over the past decade, with people aged 65 and over accounting for a larger number of A&E attendances per head than adults and children.

Deprivation

People living in the most deprived areas in England had a far higher number and rate of attendances at A&E compared to other groups (see Figure 2). A&E attendances were twice as high for people in the most deprived areas as in the least deprived.

The first large-scale research into attitudes and perceptions towards emergency care from the 2018 British Social Attitudes Survey found people living in deprived areas are more likely to prefer A&E departments over their GP to get tests done quickly; find it more difficult to get an appointment with their GP; and think A&E doctors are more knowledgeable than GPs. Separate research from the British Red Cross has shown that people who frequently attend A&E account for a substantial share of ambulance and hospital activity and often face common factors including housing insecurity, homelessness and mental health issues.

Conditions

One of the defining characteristics of emergency medicine (and general practice) is its undifferentiated case-mix, ie, patients attend an A&E department without prior testing or categorisation of their medical condition and health needs. A new emergency care dataset has been launched to capture more detailed information on why people come to A&E and what treatment they receive. From early experimental data from this source, some of the more common reasons for attending A&E included abdominal pain, chest pain and limb injuries. 

Winter

Winter is the one of the most challenging times for health and care services in general and A&E departments in particular.

Although the volume of A&E attendances is not substantially higher in winter, the demand for hospital admissions and more intensive medical care increases. Demands can rise due to increased prevalence of influenza-like illness, respiratory diseases associated with colder weather such as asthma and pneumonia, and infectious winter vomiting bugs like norovirus.

These pressures also affect NHS staff, further adding to pressures on services as staff sickness increases over winter. The supply of hospital beds can also be heavily affected by norovirus outbreaks, which can lead to entire wards being shut and deep-cleaned. This combination of increased demands and reduced capacity leads to patients waiting longer in A&E departments over the challenging winter months.

As staffing pressures and reductions in the number of hospital beds have become endemic to the NHS over recent years, long waiting times in A&E departments throughout the year are common.

Covid-19

During the Covid-19 pandemic NHS leaders encouraged the public to come forward if they needed NHS care. However, due to a range of factors including the availability of services, the impact of national restrictions and changing public views on accessing services, the number of A&E attendances fell sharply after the March 2020 national lockdown in England before returning to pre-pandemic levels in mid-2021 (see Figure 3). 

National data from a large sample of A&E departments suggests that the ‘missing’ attendances during Spring 2020 were not limited to minor conditions, with sharp falls in the number of patients going to A&E for heart conditions for example.

Waiting times for A&E care continue to be challenged as hospitals respond to the immediate demands of Covid-19, tackle backlogs for planned hospital care, and cope with staffing shortages. In April 2022, waiting time performance in A&E departments was among the worst recorded in modern data collections. Only 72 per cent of people were seen within four hours in A&E (compared to the target of 95 per cent) and no NHS trust reported that it achieved the national standard.  

Pressures are rising on A&E departments and patients are waiting longer for the care they need as national performance targets are routinely missed. 

High levels of hospital bed occupancy, delays in transferring patients out of hospital, and staff shortages throughout the urgent and emergency care system have all had an impact on A&E waiting times over recent years. 

The four-hour A&E waiting time standard is one of the most high-profile indicators of how the NHS is performing. The sustained declines in performance against this waiting time standard place a significant toll on patients and staff alike and are a clear indication of the pressures the wider health and care system is under.